Hospital program helps cut repeat customers

Area medical practices teaming up to minimize patients’ hospital trips

Recorder/Paul FranzPaul Hadsel of Greenfield weighs himself every morning, charting it on a calendar, to make sure he isn’t gaining or losing too much weight.

Recorder/Paul Franz91 year old Paul Hadsel of Greenfield gets his meds and his day organized at his kitchen table on Monday.

Recorder/Paul Franz91 year old Paul Hadsel of Greenfield gets his meds and his day organized at his kitchen table on Monday.

Recorder/Paul FranzMedical professionals at The Baystate Franklin Medical Center meet in the conference room at the hospital to discuss reducing re-hospitalization of released patients on Friday.

Juanita Tudor Lowrey, age 86, poses with a photo of her father, Civil War veteran Hugh Tudor Tuesday, March 19, 2013, in Kearney, Mo. Lowrey received pension benefits related to her father's Civil War service until she was 18 after her father died when she was 2 years old. (AP Photo/Charlie Riedel)

GREENFIELD — The first thing 90-year-old Paul Hadsel does every morning is walk across to his bedroom window, stand on a scale and write his weight on a calendar.

After multiple hospital visits over the past decade, for double pneumonia and an irregular heartbeat, Hadsel is doing everything he can to avoid another emergency room trip.

He has weaned himself off foods that contain salt — “All the good stuff,” he says, with a chuckle — and checks his feet for swelling from excess fluids. And if his weight ever goes above 173 pounds, he’ll give his primary care doctor a call to make some minor adjustments to his medication.

It’s a multi-pronged strategy that’s being promoted by a team of local medical organizations — who have worked for the past two years to minimize a person taking multiple trips to the hospital for the same medical condition.

In March 2011, Baystate Franklin Medical Center joined about 50 other Massachusetts hospitals in creating a team to focus on reducing readmissions, and in the past two years, the STAAR (State Action on Avoidable Readmissions) Cross-Continuum Team has worked on several initiatives that improve the communication between patient and caregivers.

The team includes representatives from the hospital, Baystate Medical Practices, Connecticut River Internists, Franklin County Home Care Corp., Hospice of Franklin County, Poet’s Seat Nursing Home and Valley Medical Group.

On a local level, it works to keep patients happier and healthier, by reducing their trips to the emergency room. The idea is that by a person taking daily actions to monitor health and understanding information about his or her medical conditions, problems that once led to a trip in an ambulance can now be solved before it comes to that.

For example, consider the congestive heart failure tool that all patients receive when they’re discharged. Modeled after a stop light, it provides a list of things for a person to check daily — for instance the way Hadsel records his weight each morning and looks for swelling — and assigns three color zones: green, yellow and red.

If a person finds after a self-check that he has moved out of the default green zone, he can call up his primary care office and tell them, “I’m in the yellow zone.”

Because of the two-year collaboration among medical practices, staff will know exactly what that means and can recommend dietary or medical adjustments over the phone, said Nancy Woodring, who heads up the STAAR team and works as a performance improvement coordinator for BFMC.

“Before this program what they might have said was, ‘Come to the emergency department,’ ” she said.

In the eyes of STAAR team members, the congestive heart failure zone tool has been successful. They’re able to help the patient immediately, and make a note to follow up and see if the person is consistently back in the green zone.

“There’s really no holes for the patient to fall into. Someone’s there to catch them,” said Susan Welenc, care manager at Connecticut River Internists. “They have more than one way of getting information or knowing that other people are looking out for how they’re doing.”

In the coming months, the zone tool will be rolled out for pneumonia, heart attacks and the lung condition COPD ... chronic obstructive pulmonary disease, said Woodring.

Part of the team’s work has also focused on reenforcing information that may be lost when a doctor explains it to a patient in the hospital room.

Before a person leaves the hospital, BFMC employees now call the individual’s primary care practice and schedule an appointment for the following week.

That follow-up allows the primary care office the chance to repeat instructions given to a patient in the hospital. Team members have even begun using a “teach-back” approach, where they’ll tell the patient key information and then ask them to repeat it back to them to ensure they understand it.

The same is true for medication instructions — which team members said often can be tricky if a person is instructed to take multiple forms of medicine, in different dosages at different points during the day.

The hospital has given nurses a “cheat sheet” on how to help them explain different medications and possible side effects to a patient.

But the STAAR team is hoping to take this one step further, said Woodring, by creating a sheet that patients could take home with them. The informational sheets would use plain language and color coding to serve as a quick and easy guide for a person’s medication.

Team members said the meetings have served as a chance to brainstorm ideas, but also to become familiar with the work of other medical practices in the community. They’ve now made connections with one another.

“It’s allowed us to understand better what each other does,” said Welenc. “When something is going wrong, I know who to call.”

The goal of reducing readmissions is being promoted as a cost-saving measure in federal and state conversations about health care reform, and the federal government has begun penalizing hospitals for a high number of readmissions by reducing its reimbursements for Medicare, the federally funded program for the elderly.

One year of data suggests that the program can, in fact, lower the number of readmissions at BFMC.

During a three-month period last year, from April to June, the hospital saw seven former congestive heart failure patients return a second time, according to data given by the hospital.

Before the STAAR team began meeting, numbers during a three-month period ranged from 22 to 31 patients, according to the hospital.